Abstract

Purpose: Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality with racial disparities in survival after its diagnosis. It has been suggested that racial disparities in survival reflect socioeconomic disparities. We aimed to determine associations between race, socioeconomic characteristics and survival in patients with HCC in Florida.

Methods: We identified HCC cases diagnosed between 1/1/2004 - 12/31/2013 in the Florida Cancer Data System (FCDS). We linked FCDS to the 2010-2014 US Census American Community Survey by census tract and the 2013 Florida Behavioral Risk Factor Surveillance System by county to ascertain population-level characteristics. We performed univariate, bivariate and Cox proportional hazards regression analyses to describe the association between race and survival.

Results: Of 10,852 patients with HCC, 77.4% were men, 13.4% were Black, 67.1% non-Hispanic White, 15.7% Hispanic, 3.2% Asian and <1% other. Blacks were younger at presentation, with a median age of 59 years compared to 64 years in Hispanics and 63 years in all other races, p<0.01. Median size of the largest tumor was greatest in Asians, 6.0 cm, followed by 5.4 cm in Blacks, 4.8 cm in Hispanics and 4.7 cm in Whites, p<0.01. Blacks were most likely to have distant disease, 18.1%, compared to 14.3% of Whites, 14.9% of Hispanics, 15.9% of Asians, and 10.4% of others, p<0.01. Only 16.3% of Blacks had surgery or radiofrequency ablation compared to 25.4% of Asians, 24.8% of Hispanics and 21.7% of Whites, p <0.01. Transplant was performed in 9.7% of Hispanics, 8% of Whites, 6.9% of Asians and 4.6% of Blacks, p<0.01.

One-year survival was 45.6% in Blacks, 52.1% in Whites, 55.4% in Hispanics, 58.1% in Asians, and 57.3% in others, p<0.01. Five-year survival was 31.7% in Blacks, 36.5% in Whites, 36.9% in Hispanics 46.2% in Asians, and 51% in other, p<0.01.Median survival was 208 days in Hispanics, 171 days in Whites, 158 days in Asians and 136 days in Blacks, p<0.01. When adjusted for gender, age at diagnosis, payer, tumor size, stage, and surgical treatment, Hispanics had 16% reduced rate of death (hazard ratio (HR) 0.84, 95% confidence interval (CI) 0.77-0.92, p<0.01) and Whites had 7% reduced rate of death (HR 0.93, 95% CI 0.86-0.99, p 0.03) compared to Blacks. Hispanics had 9% adjusted reduced rate of death (HR 0. 91, 95% CI 0.85-0.97, p<0.01) compared to Whites.

In our sample, Blacks and Asians were more frequently uninsured, 11.6%, compared to 8.1% of Hispanics and 6.3% of Whites, p<0.01. There were significant racial differences in population characteristics. For example, the census tracts where Hispanics live have the highest uninsured population and the highest percentage of participation in the supplemental nutrition assistance and/or food stamps program, compared to all other races, p <0.01. Also, Hispanics lived in census tracts where more families reported income below the federal poverty level and had lower mean household income, compared to Blacks, p<0.01

In regards to community health, in the counties where Blacks live, a higher percentage of adults have been diagnosed with diabetes, elevated cholesterol, cardiovascular disease and are obese than in the counties where Hispanic patients live, p<0.01. However, in the counties where Hispanics live, a higher percentage of adults have been told they are overweight, compared to Blacks, Whites or Others, p<0.01. In counties where Blacks lived, more adults reported having a colonoscopy, but fewer adults reported having a mammogram, compared to counties where Hispanic patients resided, p<0.01.

Conclusions: Access to care and socioeconomic differences may help explain survival differences in some settings; however, despite living in areas with similar or worse socioeconomic features, Hispanics with HCC survive longer than Blacks and Whites in Florida. Although access to transplant may inform these findings, additional contributors must be identified.